APPROPRIATE HEALTH TECHNOLOGY ’
Carlos A. Vidal*
A major health issue for develofiing countries today is how
technology and heaEth can contribute to develofiment, and
vice-versa. This article exfilores that subject by examining
some of the fundamental relationshi@ involved, and outlines a
new apfiroach to the technological improvement of health
conditions that would seem well-suited to meeting a developing
society’s true present and future needs.
Introduction: Technology and Development
Technology cannot be analyzed alone, as
an isolated occurrence. Rather it must be
viewed as a cause or consequence of other
phenomena, within a framework well-
defined by theory and practice. In particu-
lar, technology is intimately bound up
with development. So before going further
it would seem desirable to say something
about development.
If we consider development as a whole,
we can say that it is an integral process, one
rich in meaning, that embraces our
natural environment, social and cultural
relations, the educational process, econom-
ic production and consumption, personal
well-being, and of course, health. This
\
being the case, there can be no single
universal pattern of development. Instead
prevailing social, cultural, and environ-
mental circumstances will shape the pat-
tern and style of the particular develop-
ment process involved.
In this regard, we can say that the
development of a people is “auth’entic”
when it is endogenous, when that people
exercises its sovereign will and chooses its
*From a Paper presented at the Sixteenth Meeting of the PAHO Advisory Committee on Medical Research held in Washington, D.C., on 11-15 July 1977.
khief, Technological Resources, PAHO/WHO Division of Human Resources and Research.
own future-in cooperation with societies
that share its problems and aspirations, but
otherwise unencumbered by outside influ-
ences. It should be observed, however, that
such development, a comprehensive endog-
enous process through which a society
determines its own future, must tend
toward integral satisfaction of the needs of
that society or fall into contradictions.
In Latin America, development has not
taken place in a style that can be regarded
as “authentic” because there has been an
attempt to imitate the development style of
the industrialized countries-which have
optimized some elements of the process, but
which have restricted its benefits and have
thereby failed to satisfy majority needs. By
trying to impose their models they have
eliminated the endogenous component in
the less developed countries, subtly in some
cases and overtly in others, in order to
maintain their position of leadership.
This stress on “authentic” development
is important. As stated by the 1975 Dug
Hammarskjold Report (I):
The crisis of development lies in the poverty of the masses of the Third World, as well as that of others, whose needs, even the most basic-food,
habitat, health, education-are not met: it lies,
in a large part of the world, in the alienation, whether in misery or in affluence, of the masses, deprived of the means to understand and paster their social and political environment. . .
A 1974 report by the United Nations
‘Reference I, p. 5.
Research Institute for Social Development (2) said more or less the same thing:
The problem faced by the project has been the
highly uneven character of development within
developing countries: its limitation to certain areas and certain categories of the population, especially to areas and categories of the popula- tion already better off; its failure to resolve mass poverty; the apparent increase of income in- equalities and growth of unemployment even as economic growth has taken place.‘4
UNICEF (3) has concluded that:
In the developing world as a whole, some
three-quarters of the population is not being
effectively served. New generations are being
born, growing up, and living out their lives
without minimal services or basic education,
contributing much less than they could to na-
tional development, and with some becoming a
burden to themselves and to society. 5
This development style is aimed at the
well-being and development of every man,
woman, and child-not merely at the
growth of things that are only means to an
end. Its purpose is to meet needs (starting
with the basic needs of the population) and
at the same time to assure humanization of
the individual by providing him with
needed avenues for self-expression, crea-
tivity, and control over his own destiny.
Achieving Authentic Development
How is development to be given this
style? The answer is by adapting develop-
ment naturally to the ways in which men
and communities wish to shape the mate-
rial basis of their lives; by basing develop-
ment on the technologies they now use and
on the relationships existing between their
social systems and their natural environ-
men ts ; and by gearing development to
existing forms of social organization and
values.
The limitations on development of this
kind are not strictly defined in terms of
abundance and scarcity, or even (as some
would have us believe), in terms of
4Reference 2, p. S. 5Reference 3, p. 5.
education and ignorance. They are defined,
first of all, by our own capacity to set out
freely on a new road of our own choosing.
That is, as things stand now, these
limitations are chiefly social and political.
And in this regard, major structural
changes will be needed to promote equality
and to liberate the true creative energies of
the communities involved.
As all this implies, authentic development
is a process that fosters self-confidence and
self-reliance by applying science and tech-
nology, not to existing consumption pat-
terns, but to the bulk of the population’s
present and future needs. This naturally
requires a good measure of reorientation-
and hence control-of science and tech-
nology; for it is only a slight exaggeration
to say that he who controls science and
technology can control development.
In sum, for Latin American development
to acquire a more authentic style, new
direction must be given to science and
technology. But once we can control
science and technology (as indeed we must),
we can control our own development.
Controlling Science and Technology
The term “control” in this context
means social control rather than control by
any individual or restricted group. For
real as our cultural dependence is, it will
do no good merely to react emotionally
against it. What we must do is throw off
the present image of ourselves and create
the conditions needed for generation,
adaptation, and social control of a science
and technology that will genuinely serve
our countries’ needs.
Strictly speaking, technology is the appli-
cation of science. Though today we are
increasingly inclined to equate the two, we
must acknowledge that they have not
always traveled the same road. Indeed, a
good number of analyses have lately shown
that science and technology progress more
tendency to lump them together is based on
the explicit understanding that scientific
research (which has new knowledge as its
ultimate goal) lays the foundations of
technological progress. For its part, the
scientific community has recognized this
intimate connection as a way to justify
financial support for scientific research. As
a result, science is coming increasingly to
share the blame for problems caused by
technology, but has not always shared the
credit for technological gains. Contradic-
tions of this sort invariably arise when
science and technology fail to work together
toward a higher goal: the forementioned
satisfaction of social needs.
There is a fundamental difference,
however, between the technology of earlier
eras and that of today. The difference lies
in the capacity to make quick and practical
use of new scientific knowledge. That is,
present-day technology can absorb the most
recent findings of basic research and
quickly turn them to practical account. So
even though technological progress has
heightened our awareness of the lack of a
direct interrelationship between science and
technology, new scientific knowledge is
more speedily put to use.
Specific Problems
This point underscores two basic prob-
lems facing Latin American development.
The first is an inability to use available
knowledge and resources. The second,
intimately bound up with the first, is a
perennial insufficiency of economic re-
sources.
Consider the first problem. Modern
science and technology are descended from
the Industrial Revolution that began in
England and much of Europe in the 19th
Century. In those countries and their
European and North American offshoots,
science and technology grew within a
certain socioeconomic context, in the course
of fast-paced industrialization. In Latin
America, on the other hand, science and
technology were acquired at second hand,
through a cultural process. In this regard,
the science and technology of health are no
exception. Many of the anomalies that
amaze us today spring from the merely
cultural introduction of health knowledge
and methods that evolved elsewhere to meet
other conditions.
The second problem, insufficient eco-
nomic resources, compelled us to import
capital goods just as we imported culture.
This, in turn, saddled us with costly
science and technology which were inade-
quate to solve problems for which they
were not designed. The interaction of these
two problems thus created a vicious circle,
one that prevented us from creating
adequate science and technology, and even
from effectively adapting science and tech-
nology to our particular conditions.
What we require is thus contrary to what
we have. Instead of science and technology
that actually generate needs, we require a
science and technology that is generated in
response to present and future needs.
In the developing countries, cultural
importation of science and technology
meets the felt needs of relatively small
“developed” groups. The great majority of
the people, though co-existing with these
small groups, have not yet been brought
into the development process. However,
exposure of this majority to imported
science and technology generates new felt
needs that the majority would like to
satisfy, but which it usually cannot satisfy
for lack of money or purchasing power.
Thus a new problem is created. To the
generation of needs is added the majority’s
frustration at being unable to acquire the
products of a technology to which it has
been exposed.
In contrast, a development style geared
to meeting a developing country’s present
and future needs starts by striving to
eliminate misery. And it behooves us,
intersectoral framework, to seek this elimi-
nation of misery by concentrating upon
satisfaction of health needs. This job of
satisfying health needs, of course, is quite
different from merely helping those who
are ill to recover the health that they have
lost.
A New Approach to Health
The sources of human health are diverse
(4), but they certainly include the follow-
ing: (1) environmental factors, (2) social
factors, (3) group behavior patterns, (4)
individual behavior patterns, and (5)
health care.
The data show that in both developed
and developing societies the first four
elements’ impact on health tends to be
decisive. In comparison, medical techniques
for disease prevention and treatment are
much less important and have much less
priority in disease eradication than mea-
sures tending to improve nutrition, sanita-
tion, and housing. Therefore, the critical
health problem for any society is to develop
the cultural values and social and political
relations that make these sources of health
available to all.
Keeping these points in mind, if we take
a closer look at existing possibilities we find
that satisfaction of health needs has been
limited by the same causes that have
prevented our countries from adopting a
more effective development style. Logical-
ly, then, this new approach to health calls
for a new approach to technology. And this
new approach to technology implies a
fundamental shift from imitation to in-
novation.
Innovation, however, implies not only
creativity but also adaptation of the re-
sources we already have in order to arrive
at a new and appropriate technology. In
the health field, such a technology should
(1) tend to satisfy the health needs of the
majority; (2) foster a humane and creative
health service; (3) make the best possible
use of local resources; and (4) involve
extensive public participation.
These basic guidelines for an appropriate
health technology should be used in
formulating alternatives, which should be
weighed in terms of their effectiveness,
efficiency, acceptability, simplicity, and
feasibility. To adopt the reverse procedure
is incorrect. That is, if we put this last set
of criteria before the first we might ignore
such fundamental needs as development of
new alternatives and fostering of self-
sufficiency through community participa-
tion.
In sum, appropriate technology should
be developed in a manner suited to the
present and future resources, capabilities,
and needs of the different communities and
societies involved. Such technology should
of course be closely linked to science: but at
the same time it should be broadly
participatory, inspired not only by the
contributions of professional specialists but
also by the contributions of laborers,
farmers, and their communities. As Charles
Susskind (5) points out in his book
Understanding Technology,
One of the requirements of a satisfactory system
of technology assessment would thus seem to be
more active involvement of those “whom it may
concern.” The term particifxztory tech-
nology has been coined for this concept.6
The concept of appropriate technology is
intimately bound up with the concept of
“pre-transfer .” It is no longer acceptable to
consider unlimited transfer of technologies
from the industrialized or developed coun-
tries to the developing countries. Pre-
transfer offers a country the opportunity to
analyze its present and future needs, to
utilize an information system that can tell
it about technological experiences in other
countries-successes, failures, the ap-
proaches taken and the results attained-
and to choose the technologies most appro-
priate for the style of development desired.
Naturally, such pre-transfer -activities also
include allocation of funds for research
and development directed at adaptatio’n or
creation of appropriate technologies.
Within this framework, an appropriate
health technology should be directed at
dealing with problems that impede its new
approach to satisfaction of health needs. At
present we can say that the resources re-
quired to meet these health needs are not
scarce so much as they are badly distri-
buted, and that this circumstance is
aggravated by uncritical imitation of im-
ported models. In this regard, the introduc-
tion of “universalistic” criteria has only
served to stimulate further the rise of
health care models that are economically,
socially, culturally, and ecologically un-
sound.
We are thus faced with an either/or
proposition: We can try to meet health
needs either by applying “universalistic”
criteria or by applying what might be
called “architectonic” criteria tailored to
actual, specific situations. Therefore, the
new approach described for meeting health
needs depends not only upon the socioeco-
nomic considerations previously discussed,
but also upon the following: (1) realloca-
tion of resources to meet real present and
future needs; (2) integration of the health
services with other development services:
(3) adaptation of these development services
to specific circumstances in such a way as
to place maximum reliance on local re-
sources; (4) adoption of a strategy of
decentralization that fosters community
participation and is in harmony with the
political structure of the country involved:
(5) dedication of research to the solution of
specific community problems-without
neglecting opportunities to generate “new
knowledge”; (6) training of manpower
resources for the health field in accord
with these new strategies.
It should be noted, of course, that the
degree to which these activities are carried
out will depend largely on the political
course selected by each of the sovereign
nations involved. In addition, it would
seem worthwhile to mention a few other
points about the first three activities listed:
1) Reallocation of resources to meet
present and future needs. This realloca-
tion is limited by various circumstances.
Among these are the cost of many scientific
and technological innovations (such as
renal dialysis and intensive care units) that
can at times result in spectacular life-saving
triumphs. Adding to this problem, the cost
of curative medicine in general can be
expected to rise even further, in concert
with the high cost of providing and
maintaining such innovations; and the
technologies involved can be expected to
continue promoting increased medical
specialization. Taking all this together, it
would seem that if the curative side of
medicine remains predominant (6), and if
treatment-oriented professionals continue
to dominate medical practice, preventive
health will remain a sickly stepchild (7);
and the climate for public debate and
decision on the question of transferring
resources from expensive health care to
other cheaper and more effective mea-
sures will never be any better than it is
today.
2) Integration of health services with
other development services. I concur with
Gunnar Myrdal (8) when he stresses the
importance of integrating health initiatives
with other socioeconomic, institutional,
and political initiatives.
3) Adaptation of services to specific
circumstances so as to place maximum
reliance on local resources. This adaptation
is intimately bound up with a decentraliza-
tion strategy that promotes community
participation. In fact, adapting and using
local resources without such participation
reduces this innovative feature to just
another way of making the community
recognizing that it is an entity capable of
shaping its own destiny.
. . .
If we reduce the definition of technology
to “the way to make things”-encompassing
the knowledge of how to make things and
the instruments for making them derived
from science or from unscientific but fruit-
ful experience, failures, and successes-
then an appropriate health technology will
be a new and proper way to introduce
needed changes in the factors mentioned
above. Introduction of appropriate technol-
ogy will also offer an economical method
for reallocating resources- a method that
enlists community participation and relies
chiefly on local resources.
The effectiveness of such actions will
depend not so much on the instruments
available as upon a knowlege of how to
make the specific changes involved. Hence
appropriate technology is not synonymous
with either high-cost technology or with
unsophisticated low-cost technology. It is
synonymous with the technology best-suited
to meet overall present and future needs.
Other key features of appropriate technol-
ogy include the following:
l Besides being economically feasible, an
appropriate technology must be adaptable
to social and cultural conditions.
l An appropriate technology must be
socially as well as economically cost-effec-
tive.
l An appropriate technology must ac-
knowledge the existence of alternative
approaches for satisfaction of health needs.
l An appropriate technology must foster
self-reliance and self-confidence.
Implications for Research
As previously noted, while basic research
generates new knowledge, technological
research places this knowledge at the service
aims, encouragement must be given to the
designing of national research policies that
will promote both basic and applied
research directed at providing for majority
needs. A national policy on technological
research, for instance, should emphasize the
need to design machinery for identifying,
choosing, modernizing, and creating appro-
priate health technology. Such a research
policy-seeking the development of appro-
priate health technology-must direct its
attention to meeting the following basic re-
quirements:
(a) Establishment of a simple and easily
accessible system for acquiring, recovering,
and distributing information. Development
of an appropriate technology requires im-
provement of information systems. Coun-
tries, communities, and citizens must be
able to inform others and be informed
about the facts of development, develop-
ment styles, the implications of science and
technology, and the inherent conflicts
involved. At the international level, an
effort should be made to communicate the
experiences of other peoples-their suc-
cesses and failures-as objectively as possi-
ble, recognizing cultural, social, political,
and economic diversity, so as to facilitate
genuine cooperation among peoples. At the
national level, information and education
work should be directed at building up
public awareness of what is being consid-
ered so as to achieve maximum citizen
involvement in the decision-making proc-
ess .
(b) Development of human resources in
the field of technology, chiefly through
support to research programs that will
provide training for research workers.
Research is fundamental to the technologi-
cal process. Nevertheless, it is sometimes
asked whether the technological process is
compatible with so-called basic research.
We can answer “‘yes” if we regard basic
research, like art, as being carried on by
individuals who are driven in that direction
basic research only in terms of salaries,
contracts, and administrative obligations-
that is, as just another professional under-
taking, then we must answer “no”. In fact,
basic research is somewhat analogous to
biological mutation: the results are difficult
to foresee.
To carry the analogy further, how-
ever, applied science acts rather like the
environment: It selects discoveries and
places them at the service of the community .
Without basic research there is no dis-
covery, and without applied science there is
no service to the community. In our view,
basic research is an essential component of
the work to improve health: nor is research
confined to biology, for social research-
social epidemiology, social anthropology,
etc.-is also essential to the style of
development that we propose. It is equally
important, however, that this research be as
comprehensive as possible, and that it have
the interdisciplinary character typical of
modern scientific research.
Today the interdisciplinary character of
scientific work is manifested most strongly
in research (8). Educational processes are
still far from interdisciplinary; but when
research lacks the ability to be interdisci-
plinary, this constitutes a specific failing of
the scientific system. As Barry Commoner
(9) has pointed out:
There is, indeed, a specific fault in our system of science, and in the resultant understanding
of the natural world, which, I believe, helps to
explain the ecological failure of technology.
The fault is reductionism, the view that
effective understanding of a complex system can
be achieved by investigating the properties of its
isolated parts. The reductionist methodology,
which is so characteristic of modern research, is
not an effective means of analyzing the vast
natural systems that are threatened by degrada- tion.7
(c) Definition of pre-transfer mechanisms
for allocating national and international
funds to support research and development
7Reference 10. p. 189.
of health technologies for the developing
countries. Here it should be stressed that
before any loans are made for development
of health services, resources should be
earmarked for pre-transfer activities re-
lating to “high-risk” projects. Such pre-
transfer activities, as we have already
pointed out, should be dedicated to find-
ing, choosing, analyzing, adapting, and
creating appropriate technology.
(d) Promotion of both “vertical” and
“horizontal” technical cooperation. To
expedite creation of appropriate health
technology, the developing countries must
work together, communicate their experi-
ences, share the burden of solving innu-
merable health problems, coordinate to
obtain external financing, etc. To accom-
plish these things they must establish
procedures to promote technical coopera-
tion within agencies and countries (“verti-
cal” cooperation) and between developing
countries (“horizontal” cooperation).
(e) Encouragement for study and analysis
of how the development of appropriate
health technology is hampered by copy-
rights, royalty payments, hard-currency
purchases, etc., so that later the developing
countries may together propose a new inter-
national order in this field. For it will not
be possible to adapt much of the desired
technology, disseminate sufficient informa-
tion, fully maintain equipment, etc., so
long as the present situation remains
unchanged. In proposing a “new world
economic order” the Third World countries
have already put forward general recom-
mendations along these lines. What is
needed now is an effort specifically geared
to health.
Three Types of Appropriate Technology
It is felt that three general areas need to
be covered in the course of developing
appropriate technologies. These are as
follows: (a) the development of appropriate
development of appropriate technologies in a tool for analyzing and refining the
administration; and (c) the development of various methods, materials, types of equip-
appropriate technologies in education. ment, and logistical arrangements used in
The health technologies (a) are used to the education process. Naturally, such a
attend directly or indirectly to the needs of technology would be found at all stages of
persons, groups, and the environment; this educational process-including selec-
administrative technologies (b) are used to tion of students, assignment of tasks in
organize and administer combinations of analytical studies, transmission of knowl-
resources employing health technologies; edge, training in specific skills, and
and educational technologies (c) are used to evaluation.
prepare and train human resources. These An appropriate technology in education
three types of technologies differ in accord recognizes that individuals learn at paces
with variations between their respective different from the pace of self-instruction
fields. required for development. Taking this into
account, it develops learning strategies for
Appropriate Technology in Education acquiring skill, ability, or mastery in a
particular activity or related set of activi-
We could cite lines of research that ties.
should be promoted in each case; but since
each country’s true needs are distinct, we Supporting Elements
think this matter should be left for each
country to resolve in its own way. However, The various areas for technological
in my own field-the training of human development in health that we have just
resources-I would like to present some mentioned all depend on common support-
general propositions that an appropriate ing elements. These common supporting
technology in education should take into elements (which themselves need to be
account. promoted) include diagnosis and documen-
First, curricula must never be predeter- tation of health problems, basic research,
mined or borrowed: instead they must be production of informative materials, train-
derived from analysis of health needs and ing, and regional technical cooperation.
provision of health services, and they must Depicting the relationships between these
be the subject of ongoing consultation. supporting elements and the various tech-
Appropriate technology in education, nologies they support results in a two-
though itself no discipline, involves an dimensional matrix. Then, when the pro-
interdisciplinary approach to the entire gram areas established by the Ten-Year
teaching-learning process. In this it serves Health Plan for the Americas are added this
as a research tool, and at the same time matrix becomes three-dimensional.
opens up new fields for application of
available technological resources. It thus &n&&ng &mark
provides a viable approach to the problems
of educational planning, organization, and In closing, it is not proposed that techno-
administration. logical research be done, but rather that
At the same time, appropriate technology mechanisms be provided that will permit
in education involves a sense of creation, development of appropriate health technol-
invention of new procedures, discovery of ogy-a process which in our view is more
new resources, and development of a new important than technological research at
organization for accomplishing a purpose our peoples’ present level of development.
“technological package” exists in our own package tied. Hence, as a final recommen-
countries that is securely tied. This package dation, I think we should start by undoing
is alleged to contain the health technologies this package in rural or marginal urban
that are most adequate and important. This areas that are still unaffected or nearly so.
could help provide the basis for a package of Extension of health coverage to such areas
“appropriate health technology.” However, could then act as a strategic springboard
the vested interests involved, the ideas from which to lauch an effort to redesign
imported, the dominant ideology, etc., the entire technological component of the
constitute strong bonds that keep the rest of the health system.
This article seeks to analyze certain relation- ships between science, technology, development, and health within a frame of reference well-defined by theory and practice.
There is no “universal” style of development; rather, the development process must be adapted to a given society’s specific cultural features and to its natural environment. In addition, to be truly effective, this development process must address basic majority needs and must be directed at providing the individual with needed avenues for self-expression, creativity, and control over his own destiny.
In seeking to apply science and technology to this process, however, Latin America (as well as many other developing areas) encounters a number of major problems. For one thing, most science and technology has been acquired at second hand, through cultural “importation” from abroad, so that what arrives is apt to be ill- suited to the receiving society’s special needs. For another, the development process in Latin America confronts a very limited ability to use the knowledge and resources that are available, as well as a perenniel insufficiency of economic resources. Not surprisingly, the combined result of all this has generally been importation of capital goods and technologies that are both expensive and highly unsuited to solving the major development problems at hand.
One major development problem is obviously satisfaction of basic health needs. However, data from both developed and developing coun- tries show that environmental factors, social factors, group behavior patterns, and individual behavior patterns have a far greater impact on health than do existing medical techniques for disease prevention and treatment. Therefore, the critical problem for any society is how to develop the cultural values and social and
political relations that will tend to make good health available for all.
Logically, this approach to health calls for a new approach to technology, and this new approach to technology calls for a fundamental shift from imitation to innovation. Specifically it calls for the following actions:
l A reallocation of resources to meet real
present and future needs;
l Integration of the health services with
other development services;
l Adaptation of these development services to
specific situations in such a way as to place maximum reliance on local resources;
l Adoption of a strategy of decentralization
that fosters community participation and is in harmony with the political structure of the community involved:
l Dedication of research to the solution of
specific*community problems:
l Training of manpower resources for the
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(3) United Nations Children’s Fund. A Strate- gyfor the Basic Services. (Code 378-76-10M) New York, 1976.
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(5) Susskind, Charles. Understanding Tech-
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(6) Pan American Health Organization. “Report of the Second Committee of the PAHO/WHO Textbook Program for Teaching of Preventive Medicine.” Human Resources Series, No. 22, 1975.
(7) Carlson, Rick. The Goal of Medicine.
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(8) Myrdal, Gunnar. Asian Drama: An In-
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(la) Commoner, Barry. The Closing Circle.
Alfred A. Knopf, New York, 1971.
Children Under 5, Adults 65 or ti
The needsfor child care services in Latin America have been rapidly
increasing and are likely to continue to increase. In 1975, children
under 5 years of age comprised 16 per cent of the population in
Latin America, and 8 per cent of the population in Northern America,
over 51 million and 19 million, respectively, for that year.
Although the proportion of the pofiulation aged 65 or over is relatively
small in Latin America, the number in this age groufi is expected to
increase from 12 million in 1975 to 28 million in the year 2000.
The need for substantial increases in services for chronic diseases
and disabilities associated with old age, and general geriatric
services is clearly indicated by this trend.
